Provider Demographics
NPI:1013892793
Name:JORDAN, CHARISSA MARIE ELY (FNP-C)
Entity type:Individual
Prefix:
First Name:CHARISSA
Middle Name:MARIE ELY
Last Name:JORDAN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:CHARISSA
Other - Middle Name:MARIE
Other - Last Name:ELY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:45 PINECREST AVE
Mailing Address - Street 2:
Mailing Address - City:MASHPEE
Mailing Address - State:MA
Mailing Address - Zip Code:02649-4372
Mailing Address - Country:US
Mailing Address - Phone:774-392-2906
Mailing Address - Fax:
Practice Address - Street 1:107 COMMERCIAL ST
Practice Address - Street 2:
Practice Address - City:MASHPEE
Practice Address - State:MA
Practice Address - Zip Code:02649-6507
Practice Address - Country:US
Practice Address - Phone:508-477-7090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-11
Last Update Date:2025-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2318744163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse